Monday, June 12, 2006

RCM proposal met with widespread anger

Not suprisingly, the Royal College of Midwives' repugnant proposal to make individuals pay for epidurals in labor was greeted with widespread anger throughout the UK.

Mary Newburn, the head of policy research for the National Childbirth Trust (NCT), said charging was out of the question:
The NCT does not support the proposal to charge women for an epidural. This would be adding insult to injury, when women are often denied access to other options that would help them cope during labour. It is also an impossible judgment call to decide when some women need an epidural for pain relief and others don't. We need to build up women's confidence so that they can cope with the pain of a normal labour, rather than take away one of the choices that they have come to expect.

Those who manage maternity services should be thinking about how they can promote the kinds of maternity care and birth choices that increase straightforward births and women’s sense of well-being and empowerment.

India Jones of the Times wrote:
Is the RCM suggesting that women who scream for epidurals are just sissies and should up their pain threshold, pronto? Or is it saying — outrageously — that opting to have pain relief is somehow an “unnatural” decision, and one which it’s not up to the mother to make? And what about women who can’t afford to pay and have low pain thresholds — do they just lie there screaming in agony because they are skint?

As a veteran of three C-sections (and three epidurals), I’m bored to tears by the fanatical zeal of institutions like the RCM (and the blimmin’ National Childbirth Trust), with their fixation on natural childbirth. They love nothing better than making you feel like a failure because you didn’t tear from front to back, or leave claw marks on the bed.

The thing about childbirth is this: it doesn’t matter a jot how you get the baby out, as long as it’s out and healthy. Have whatever birth works for you. And shut up about it.
Lowri Turner writing on the Wales National website:
We mere mothers, the ones who will be affected if this plan comes in, are not to be invited to comment. This tells you a lot about the relationship between mums and some midwives. Yes there are great ones, but there are others who are only a shade off Cruella de Vil.

The worst midwives don't have kids of their own but feel they can tell us exactly how to behave while we are having ours. When you arrive at the labour ward they give you a bored look that says, 'Oh, here comes another one and, oh, God, and she's got a birth plan'. Some even have a sadistic streak. If you express a preference for pain relief, they give you a withering look as if to say, 'What a baby'...
At a stroke, the Royal College of Midwives managed to convince many people that their worst fears about midwives are true. Midwives don't want to empower women, they want sneer at them, belittle them and hurt them, all to preserve the midwives' idea of an appropriate "birth experience".

See original comments here.

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30 Old Comments:

I am sorry, but as many may agree, Lowri Turner is hardly the most appropriate woman to quote. This makes me just laught at your blog even harder.

By Anonymous Anonymous, at 9:01 PM  

It was interesting to read the three examples offered in your post.

The first, a representative of the NCT offers some insightful suggestions for the benefit of all laboring women. The other two simply proclaim their anger.

Who or what is their anger really toward or about?

I doubt that it's truely about advocates [NCT] of natural childbirth. I think it comes from a primal place much deeper than that.

Honestly, if I needed a medical managed birth I wouldn't care at all what anyone else thought of it, just as I don't care what anyone thinks about my planned home births with midwives that were unlicensed [gasp] at the time! The best decision of our family's life!

By Anonymous seriously, at 10:36 PM  

"Who or what is their anger really toward or about?"

Their anger is toward a group of women who are asking the government to PUNISH women who want pain relief in labor by imposing a $1000 fine on them.

By Blogger Amy Tuteur, MD, at 10:56 PM  

the problem is, the normal hospital birth requires an epidural. One can't be expected to put up with the excess pain a normal hospital birth incurs over a normal home birth.

By Anonymous Anonymous, at 11:19 PM  

Mary Newburn acknowledged at the beginning of her statement on behalf of the NCT, " Given that we are in desperate need of more midwives, it might be better to direct more resources into midwifery staffing and less into high-tech treatments like epidural anaesthetic. The NCT..."


India Jones of the Times wrote...

I believe you meant India Knight (a columnist, not spokesperson as far as I can tell), rather than Jones.

But anyway, it seems this is old news (February '06) and was a ploy of the RCM to call attention to the rising Cesarean rate and to protest the medicalization of birth.

By Anonymous clever ID, at 11:21 PM  

I wasted some time and went to see what some UK midwives really thought of this proposal and the general comment was "are they [RCM]for real"?

Might this have been an attempt to provoke a debate about the ridiculously high levels of cesareans, epidurals, and medical interventions, in general?

It's a proposal for debate at the RCM conference.

Does every woman have an immediate right to an epidural on demand as she was walks through the labour suite doors?

Do we have that level of here in the US? No, not even for profit.

By Anonymous seriously, at 11:24 PM  

Amy said, "Their anger is toward a group of women who are asking the government to PUNISH women who want pain relief in labor by imposing a $1000 fine on them."

Oh, then you shouldn't mind if we [natural childbirth advocates] seem a bit bitter [as you repeatedly accuse] about having to pay out THOUSANDS more for attended home birth to avoid routine interventions such as epidurals that are so frequently needed in hospitals?!

By Anonymous seriously, at 11:55 PM  

>>At a stroke, the Royal College of Midwives managed to convince many people that their worst fears about midwives are true. Midwives don't want to empower women, they want sneer at them, belittle them and hurt them, all to preserve the midwives' idea of an appropriate "birth experience".<<

I think this post is more telling about you and your beliefs. This shows how irrational you are.

Peace OUT

By Anonymous Anonymous, at 12:37 AM  

"Oh, then you shouldn't mind if we [natural childbirth advocates] seem a bit bitter [as you repeatedly accuse] about having to pay out THOUSANDS more for attended home birth to avoid routine interventions such as epidurals that are so frequently needed in hospitals?!"

I don't mind since it isn't the same thing, and your attempt to compare it shows demonstrates a lack of understanding about what is happening here.

What the RCM is asking for is equivalent to women wanting natural childbirth IN THE HOSPITAL being forced to pay a $1000 fine.

Their proposal is unethical, sadistic, and discriminatory against women who are not rich. Any midwife or advocate who does not disavow it is simply demonstrating the fact that midwifery is NOT about empowering women it is about empowering MIDWIVES. It confirms the worst caricatures of midwifery.

Is this what midwifery means to you?

By Blogger Amy Tuteur, MD, at 6:58 AM  

Clever id:

"was a ploy of the RCM to call attention to the rising Cesarean rate and to protest the medicalization of birth."

Well that's wishful thinking, isn't it?

By Blogger Amy Tuteur, MD, at 7:00 AM  

Well that's wishful thinking, isn't it?

I am not the Google master you are. Perhaps you can find something later than February 2006 to show this is an active campaign. That would exclude May opinion/blog pieces moaning about it.

By Anonymous clever ID, at 10:00 AM  

the problem is, the normal hospital birth requires an epidural. One can't be expected to put up with the excess pain a normal hospital birth incurs over a normal home birth.

I know many women who have given birth in a hospital, with no or very minimal pain relief. Your "excess pain" claim is simply a myth and it is dishonest to make that claim.

What is true is that most women will choose an epidural if one is available. And so what? This is no surprise. Pain has some limited benefit as an indicator of damage and restrictor of movement, but labor pain is pretty useless.

It would be more fair to say
"Home birth mothers don't use epidurals! (Of course, that's because we don't have them to use...)"

By Blogger sailorman, at 11:45 AM  

Sailorman said:
I know many women who have given birth in a hospital, with no or very minimal pain relief.

You've known some fortunate women! But that is anecdotal.

Your "excess pain" claim is simply a myth and it is dishonest to make that claim.

There is usually excess pain - meaning pain that would not be otherwise experienced - when a laboring woman is kept in bed. Most hospitals require constant fetal monitoring, with the belly straps attached to the EFM machine, which seriously limits movement. Thus the woman is left with nowhere to be except bed, and that often aggravates the pain of labor. When a woman is allowed to be upright and moving freely, it really helps, and is a LOT less painful.

It's a tangent, but it's an important point. Anon 11:19 is not a liar and isn't perpetrating a myth.

labor pain is pretty useless

That's completely subjective. Some women find it VERY useful to be in touch with what's going on in their bodies during labor. It's not ALL pain. To me, THAT'S the myth. But again, that's entirely subjective. Some people find it useless and others (like me) do not.

By Anonymous wasting my breath, at 12:52 PM  

wasting my breath said...
There is usually excess pain - meaning pain that would not be otherwise experienced - when a laboring woman is kept in bed.


Hmm. I'm not really sure this is necessarily true. Where are you getting the basis for your claim?

I also take exception to your language. Laboring women are not "kept" in bed in hospitals any more than women are "forced" to induce. This is not China.

If a woman wants to get out of bed, her nurse may say no. However, this is because the woman, by entering a hospital, has said "help me and advise me in a manner which is most likely to give me a healthy infant." You are taking that phrase out of the context and this is ridiculous.

If you want to ignore the nurse, you may do so at your peril. But they won't send security in to restrain you, they'll just try to convince you it's wrong. This is not "forcing" you to stay in bed any more than a doctor will "force" a healthy 18 year old to get treatment for cancer rather than trusting a homeopathic quack.

BTW, there are also some advantages of bed labor, the most obvious one being the instant ability to rest during contractions. Even without pain relief, this can be quite helpful. WITH pain relief, many women fall asleep. Yeah, I know, they should be feeling pain, it's "natural". But sleep really isn't that bad from their perspective.

Most hospitals require constant fetal monitoring, with the belly straps attached to the EFM machine, which seriously limits movement.

You're making a belly band sound like shackles ("evil! Eeeeeevil!"). You can move around with a band. Even with wired EFM you can stand by your bed, sit in a chair, ait in bed, etc.

But in any case, this makes me wonder: would you entirely retract your objection in the face of wireless EFM?

Thus the woman is left with nowhere to be except bed, and that often aggravates the pain of labor.

Have you been to a hospital lately? The women are frequently walking around. Some are not hooked up to EFM at all; others have wireless. Yes, they walk slowly. But to put it mildly, it's not as if they would be sprinting anyway.

You're also setting up a false dichotomy, of "completely unrestricted" or "in bed." There are more than two choices.

And back to the whole 'aggravates the pain' thing. I am really not sure you are right about that. It depends on what is causing you the pain.

That's completely subjective. Some women find it VERY useful to be in touch with what's going on in their bodies during labor. It's not ALL pain. To me, THAT'S the myth.

Note that I said "pretty useless" not "entirely useless". Sure, some feedback is helpful for some women. But for an intelligent animal there is no physiological benefit to pain above a certain level. It doesn't help you, it doesn't help your baby.

With some exceptions, a lot of labor pain doesn't even serve as a reliable indicator, which is to say that "more painful" doesn't mean "bad." If it hurts like hell when you push, what are you going to do--not push?

This "painless home birth" thing is, politely, a crock of shit. The reason people get epis in hospitals are multiple:

1) They are not primed to think "pain is good". There's no reason they SHOULD think that, unless they are somehow vested in delivering without pain meds.

2) Pain relief is available. There's no way to know how many home birth women would have wanted it. And of course, OBs respect pain relief decisions more than many midwives, who generally advise against it.

3) It hurts. They would rather not be in pain. If they have had a long labor, they might catch some rest to be able to push well later (this is very common)

I mean, come on: Take a whole mess of women. Select out the ones who are unusual enough to want a home birth. Train them both in pain management techniques, indoctrinate them that the pain won't be too bad, and don't have an epi available. You really think their claims can be respected vis a vis pain management?

By Blogger sailorman, at 1:40 PM  

Sailorman,

For crying out loud! Really, now, why get so defensive?

My only point was that women have different experiences with labor and different priorities.

This really isn't the hill I want to die on, and I really don't disagree with very much of what you said. A few things before I stop reeling from your very involved response:

* In my area, wireless EFM is completely unheard of, but I imagine (no experience here) that it is an improvement.

* I have seen slight movements by the laboring mom cause the EFM to lose track of the baby's heart rate, which brings in nurses to re-adjust them. That means that movement is hampered, if the laboring mom doesn't want to stay in bed, and if she doesn't want to keep bothering the nurses. It means re-adjusting for a sitting position or for sitting on the birth ball or - well, you get the idea. It's not impossible, but it's a little bit involved and kind of frustrating.

* Do I think they're evil shackles? Well, I understand their purpose. I personally don't like wearing them during labor (only done so intermittently); I found them to be very, very uncomfortable during contractions. I don't know what other women experience, though I believe many don't mind them at all. I think intermittent monitoring should be fine for most women, and should be an option if they find the straps uncomfortable and/or restrictive.

Have you been to a hospital lately? The women are frequently walking around. Some are not hooked up to EFM at all; others have wireless.

Oh, I wish that was true here! You'd be in for a shock if you visited our local hospital. It works differently here.

Note that I said "pretty useless" not "entirely useless".

Point taken. I'm sorry if I misunderstood/ oversimplified what you said originally.

If you want to ignore the nurse, you may do so at your peril...etc

I never meant to imply that women should act against hospital policy/doctor's or nurse's orders. It's true that, as a fellow blogger worded it, "You pay for the hospital ticket, you go for the hospital ride."

I maintain what I said before. A lot of this is subjective. There are so many options available for handling labor, and women ought to feel supported in the options they choose. I have my ways of handling things, other women have their own. Why is it necessary to preach or tell someone else that their way is wrong or misguided, if it works for them?

That last part is important, so I'll repeat it: If it works for them, why argue with them about it?

By Anonymous wasting my breath, at 4:20 PM  

Pain has some limited benefit as an indicator of damage and restrictor of movement, but labor pain is pretty useless.

And here I understood it as part of homeostasis. Feeback loops and all. Hm.

btw, congrats on the baby. I had an 11 pound boy myself once (and two 10 pound girls) and now he's 7.

By Anonymous clever ID, at 8:41 PM  

Sailorman,

For crying out loud! Really, now, why get so defensive?


Give him a break. He's postpartum and suffering the lingering effects of Couvade Syndrome ;)

By Anonymous clever ID, at 8:44 PM  

clever ID said...
Give him a break. He's postpartum and suffering the lingering effects of Couvade Syndrome ;)


You almost made me spew coffee on my screen when I read that. And out my nose. heh. ;)

And here I understood it [pain] as part of homeostasis. Feeback loops and all. Hm.

Well, we're different from other animals in terms of our intelligent awareness of pain.

But biologically speaking, from my readings pain usually serves as a "don't do that" or "look out" alarm. If your twisted ankle hurts like hell when you walk, that's usually because it will damage your ankle to walk on it. And so on.

There are issues where pain is "wrong." Once your ankle is healed to a certain point, it may be beneficial in the long run to stretch it, even if it hurts. You may be doing damage per se to your ankle, but it's damage (stretching) which will be beneficial in the long run.

Still, it hurts. This is because the pain system is so simple and basic in nature that it can't distinguish between "good" damage and "bad" damage. Pain doesn't think of the long run, it's only immediate.

Then, there's what I call "useless" pain. When you have cancer, it hurts. And if that pain helps you discover it, it's a good thing. If the pain helps you limit your movements to avoid more damage, that's also a good thing. But if it just hurts without conferring any information it is a bad thing.

Much (but not all) labor pain is in the 'useless' category, and some of it is actively problematic. Which is to say the pain is helpful when it warns you of a contraction. It is helpful when it allows you to keep track of what your body is doing.

However, the degree of pain required to communicate this type of information is much less that what many women experience. A lot of that "extra" pain is useless; a twinge would work just as well.

Furthermore, some of the pain is sort of problematic. Pain which makes a mom unwilling or unable to push is bad. Pain which makes her body go haywire in response is not great. Pain which limits her ability to get in her preferred delivery position is bad.

Think of it this way: If we developed a perfect analgesic, which would significantly reduce pain and have no other effect at all on mom or baby, then moms could purely concentrate on having a safe and active delivery.

But since everyone's pain tolerance is different, some women will always be better off with pain meds. You'll probably have a safer delivery if a woman has a few shots of Nubain or an epi and can listen to the midwife, push when she needs to, etc, than if she's flipping out in pain.

btw, congrats on the baby. I had an 11 pound boy myself once (and two 10 pound girls) and now he's 7.

thanks. he's cute! and FAT! Though my wife is really the one who deserves the kudos.

By Blogger sailorman, at 10:12 AM  

Labor is the only time I can think of when the pain also creates an "alarm" (get nested, safe, ready) and where pain, for the most part, is a sign of positive production. The pain coming from contractions are a sign the body is doing what it should to expel the fetus (additional pain from fetal position; posterior for example). The pain ends when the cycle is complete fetus is expelled (of course lingering soreness may persist due to sore muscles).

This is commentary only on the "why" of pain in labor not "why should you experience it" (because I really don't care if anyone does!).

By Anonymous clever ID, at 10:55 AM  

Clever id:

"The pain coming from contractions are a sign the body is doing what it should to expel the fetus (additional pain from fetal position; posterior for example). The pain ends when the cycle is complete fetus is expelled (of course lingering soreness may persist due to sore muscles)."

Similarly, the pain coming from menstrual cramps is a sign the body is doing what it should to expel the endometrial lining. The pain ends when the cyle is complete and the endometrial lining is shed.

So should we find menstrual cramps to be empowering? Is it not "normal" to take Advil for menstrual cramps? Are women missing out on the full experience of menstruation by dulling the pain of menstrual cramps?

By Blogger Amy Tuteur, MD, at 11:32 AM  

Similarly, the pain coming from menstrual cramps is a sign the body is doing what it should to expel the endometrial lining. The pain ends when the cyle is complete and the endometrial lining is shed.

So should we find menstrual cramps to be empowering? Is it not "normal" to take Advil for menstrual cramps? Are women missing out on the full experience of menstruation by dulling the pain of menstrual cramps?


Sounds like you are crying for consistency here. What's your answer to your own question?

By Anonymous clever ID, at 12:02 PM  

My answers:
So should we find menstrual cramps to be empowering?
no.

Is it not "normal" to take Advil for menstrual cramps?
it is normal.

Are women missing out on the full experience of menstruation by dulling the pain of menstrual cramps?
no.

cleverid:
I think we're all in agreement that SOME pain (or other sensation) is arguably useful in labor to help the woman know what's going on with her body. (though even there, if she can't change her behavior based on the pain it's of questionable use. so the "useful" pain is probably pretty minimal.)

I'm curious as to whether you agree with my statements that much of the pain is not useful and that some of it may be harmful.

An example of harmful pain: Pain makes some women tense. Tension can impede labor, if you tense the wrong muscles. That's why many women who receive pain medication "suddenly" start dilating: They're not tensing up and imeding dilation. For those women, the pain of a contraction is not helpful.

By Blogger sailorman, at 1:17 PM  

so here you go a few studies related to the subject of pain in birth and even a result postpartum- wether we have studied or discovered all the intricacies of the body and how we have adapted as humans - studies have to do with funding and imagination and what is already known or suspected- we couldn't even find a retro-virus until we had equipment powerful enough to see- since you are changing things don't you think it would be wise to study what you are doing to be sure you are not harming anything---

Biol Res Nurs. 2005 Oct;7(2):106-17.

Differences between exclusive breastfeeders, formula-feeders, and controls: a
study of stress, mood, and endocrine variables.

Groer MW.

Research and Evaluation, University of Tennessee College of Nursing, Knoxville,
TN 37996-4180, USA. mgroer@utk.edu

The purpose of this study was to examine relationships among lactational status,
naturalistic stress, mood, and levels of serum cortisol and prolactin and plasma
adrenocorticotropic hormone (ACTH). Eighty-four exclusively breastfeeding, 99 exclusively formula-feeding, and 33 nonpostpartum healthy control women were studied. The postpartum mothers were studied cross-sectionally once between 4 and 6 weeks after the birth. Stress was measured using the Perceived Stress Scale, the Tennessee Postpartum Stress Scale, and the Inventory of Small Life Events. Mood was measured using the Profile of Mood States. Serum prolactin, plasma ACTH, and serum cortisol levels were measured by commercial ELISA
(enzyme-linked immunosorbent assay) kits. Results indicate that breastfeeding mothers had more positive moods, reported more positive events, and perceived less stress than formula-feeders. Reports of stressful life events were generally equivalent in the two groups. Serum prolactin was inversely related to stress and mood in formula-feeders. When breast and formula-feeders were compared to controls, they had higher serum cortisol, lower stress, and lower anxiety. Breastfeeders had lower perceived stress than controls. Breastfeeders
had lower depression and anger and more positive life events reported than formula-feeders. However, there were few correlations among stress, mood, and the hormones in postpartum mothers, and those only in formula-feeders, whereas strong relationships were found between serum ACTH and a number of stress and mood variables in controls. Postpartum mothers reported a range of stress and
negative moods at 4 to 6 weeks, and in formula-feeders, serum prolactin was related to some of the stress and mood variables. Breastfeeding appears to be somewhat protective of negative moods and stress.

PMID: 16267372 [PubMed - indexed for MEDLINE]
-----------------------------------------------------------------------------------------------------
Biol Neonate. 2001 Feb;79(2):87-90.

Labor pain effects on colostral milk beta-endorphin concentrations of lactating
mothers.

Zanardo V, Nicolussi S, Giacomin C, Faggian D, Favaro F, Plebani M.

Department of Pediatrics, Padua University School of Medicine, Padua, Italy.
vincenzo.zanardo@libero.it

beta-Endorphin (beta-EP) levels of colostral milk are approximately two-fold higher than in plasma of lactating women, in who concentrations peak at term, after the first and second stages of labor. We investigated the effect of labor pain and vaginal parturition on colostral beta-EP concentrations (beta-endorphin (125)I RIA, Incstar Corp., Stillwater, Minn., USA) of at-term nursing mother, in comparison to those having undergone elective cesarean section. Our results show that colostral milk beta-EP concentrations of mothers who delivered vaginally are significantly higher on the 4th postpartum day (6.0 +/- 0.5 vs. 4.3 +/- 0.4
pmol/l, respectively; p < 0.01) than colostral levels of mothers who underwent cesarean section. These data indicate the important influence of the labor
process on the colostral opioid galactopoiesis. It is suggested that labor and parturition pain may increase colostral milk beta-EP concentrations of lactating mothers in order to help the newborn overcome the stressful perinatal events of natural labor and delivery. Copyright 2001 S. Karger AG, Basel

PMID: 11223648 [PubMed - indexed for MEDLINE]
------------------------------------------------------------------------------------------------------------
BJOG. 2006 Apr;113(4):441-5. Epub 2006 Feb 20.

Mode of delivery is associated with maternal and fetal endocrine stress
response.

Vogl SE, Worda C, Egarter C, Bieglmayer C, Szekeres T, Huber J, Husslein P.

Department of Obstetrics and Gynecology, Division of Obstetrics, University of
Vienna Medical School, Vienna, Austria. sonja.vogl@meduniwien.ac.at

OBJECTIVE: To determine whether mode of delivery is associated with the endocrine stress response in mother and child. DESIGN: Prospective observational
study. SETTING: Tertiary care centre, University hospital. POPULATION: A total of 103 nulliparous women with uncomplicated singleton pregnancies at term undergoing either spontaneous labour for vaginal delivery or delivering by caesarean section without labour. Thirty women delivered vaginally without any pain relief, 21 women delivered vaginally with epidural anaesthesia, 23 women had ventouse extraction and 29 women underwent caesarean section with epidural analgesia. METHODS: After delivery, maternal and umbilical cord blood was
collected for determination of different stress-associated hormones. MAIN OUTCOME MEASURES: Concentrations of epinephrine (EP), norepinephrine (NOR), adrenocorticotropic hormone (ACTH), cortisol (CORT), prolactin (PRL), corticotropin-releasing factor and beta-endorphin (BE). RESULTS: Caesarean
section was associated with significantly lower maternal concentrations of EP, NOR, ACTH, CORT, PRL and BE and lower newborn levels of EP, NOR and CORT compared with all other modes of delivery. Concentrations of EP, ACTH and BE differed significantly in newborns delivered by normal vaginal delivery, vaginal delivery with epidural anaesthesia and ventouse extraction. CONCLUSIONS: The
mode of delivery and analgesia used during birth are associated with maternal and fetal endocrine stress responses.

PMID: 16489937 [PubMed - indexed for MEDLINE]
----------------------------------------------------------------------------------------------------------------
Psychoneuroendocrinology. 2006 Jan;31(1):25-9. Epub 2005 Sep 9.

Evidence that natural benzodiazepine-like compounds increase during spontaneous
labour.

Facchinetti F, Avallone R, Modugno G, Baraldi M.

Mother-Infant Department, University of Modena and Reggio Emilia, Azienda
Policlinico, Via del Pozzo 71, 41100 Modena, Italy. facchi@unimore.it

Natural benzodiazepine-like compounds (NBDZ) are present in the blood of normal people free of commercial benzodiazepine medication. In this work, we evaluated the levels of NBDZ in maternal/foetal serum during delivery after spontaneous
labour (VD) or caesarean section (CS). For both the VD (n=11) and the CS (n=11) groups (VD+CS=22), three blood samples were collected at three different times: the first was collected three days before labour, the second immediately after delivery or at fetal abdominal extraction and the third one was obtained at second day post-partum. NBDZ were measured by radioreceptor binding assay after
HPLC extraction and purification while cortisol was measured through radioimmunoassay. In the VD group, a significant increase of NBDZ levels
occurred at labour in comparison with the levels found in pre- and post-partum periods. By the contrary, no differences in NBDZ levels were found in the CS group at the three different times. The levels of cortisol in the VD group were found to be higher at labour than that determined at pre- and post-partum. Again no significant changes were found in the CS group. These findings suggest for
the first time that labour is associated with a marked increase of NBDZ which could be envisaged as a stress-related event.

PMID: 16154295 [PubMed - indexed for MEDLINE]--
-------------------------------------------------------------------------------
Stress hormones and acid-base status of human fetuses at delivery

SM Ramin, JC Porter, LC Gilstrap 3d and CR Rosenfeld
Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas 75235.

The relationship of plasma concentrations of arginine vasopressin (AVP), ACTH, cortisol, and PRL in the human fetus to mode of delivery and acid-base status has been investigated in 91 term pregnancies consisting of 4 groups based on mode of delivery, type of anesthesia, and use of ephedrine prophylaxis for maternal blood pressure control. Infants delivered vaginally after uncomplicated labors had higher umbilical cord plasma concentrations of AVP, ACTH, and cortisol than infants delivered without labor. Use of ephedrine, an alpha-agonist, during regional anesthesia was associated with elevated plasma AVP and ACTH concentrations compared to those in women receiving general anesthesia. At the time of delivery, 12 infants had acidemia (pH less than 7.20), as judged by pH of umbilical arterial blood. Their plasma AVP, ACTH, and cortisol levels did not differ from those of infants delivered by uncomplicated vaginal delivery, but were greater than those of infants delivered by cesarean section under general anesthesia. Moreover, in infants with acidemia, plasma concentrations of AVP and ACTH were significantly correlated, but PRL levels were unaffected by mode of delivery or acidemia. Elevated umbilical cord plasma concentrations of AVP, ACTH, and cortisol characterize term vaginal deliveries and are associated with intrauterine stress, demonstrating activation of the fetal hypothalamic-pituitary-adrenal axis and suggesting that AVP is important in ACTH release in the human fetus; however, PRL does not appear to be an important stress hormone.

By Anonymous Anonymous, at 1:22 PM  

There are approximately 1400 articles in the scientific literature about pain, epidurals, breastfeeding and other neonatal effects.

There are many that show the exact opposite.

By Blogger Amy Tuteur, MD, at 3:50 PM  

cleverid:

I think we're all in agreement that SOME pain (or other sensation) is arguably useful in labor to help the woman know what's going on with her body. (though even there, if she can't change her behavior based on the pain it's of questionable use. so the "useful" pain is probably pretty minimal.)


Sure. I'll agree to that since we're talking in generalities.

I'm curious as to whether you agree with my statements that much of the pain is not useful and that some of it may be harmful.

I have seen the example of what you describe (fear-tension-increased pain), but I wouldn't exactly call it harmful unless there are some exasperating influences such as abuse histories or physical anomalies that would inhibit normal physiology.

By Anonymous clever ID, at 4:10 PM  

"Pain doesn't think of the long run, it's only immediate."

I totally understand what you're saying, and I'm not saying this to pick on you. I want to point out that if this phrase were coming from a home birth supporter Amy would be rabidly talking about how pain can't "think".

By Anonymous Anonymous, at 4:53 PM  

The bigger question is not "is pain in labor beneficial" it is really "is there an increased risk of problems from invasive medical pain relief?"

And then, for those who wish to minimize those risks: "what can be done to maximize the liklihood of not getting invasive medial pain relief?"

By Anonymous Anonymous, at 4:57 PM  

"is there an increased risk of problems from invasive medical pain relief?"

Every woman should be informed of all possible risks, the she can make her own decision.

The same thing applies to homebirth. The risk of neonatal death is slightly higher, but if a woman knows that and wishes to have a homebirth, she has a right to do so.

By Blogger Amy Tuteur, MD, at 6:24 PM  

amy wrote " I am saying that there is NO scientific evidence that pain in labor is beneficial in any way."

amy I sent some evidence- and even if you counter with saying that there is evidence that disputes or refutes that is not the same is NO evidence- what might be said is there is no conclusive evidence- or there are many studies with conflicting evidence-- or that there are no studies you have read that have convinced you to change your view-- do you give your clients a complete disclosure -- how have you weighed the evidence? how I read it things even by anesthesiologists that show problems with breast-feeding and the hormone folks saying well here we go changes in stressors and you didn't even read what I sent because one shows = with epidural as long as there is epinephrine on board but there was more acidosis in the epidural group I threw that in to actually see if you read or just react-- and you did- here you can have the rubber mallet

By Anonymous Anonymous, at 2:06 AM  

"and even if you counter with saying that there is evidence that disputes or refutes that is not the same is NO evidence"

The first study is not even about pain at the time of delivery.

Second paper: "Our results show that colostral milk beta-EP concentrations of mothers who delivered vaginally are significantly higher on the 4th postpartum day (6.0 +/- 0.5 vs. 4.3 +/- 0.4pmol/l, respectively; p < 0.01) than colostral levels of mothers who underwent cesarean section. These data indicate the important influence of the labor
process on the colostral opioid galactopoiesis. It is suggested that labor and parturition pain may increase colostral milk beta-EP concentrations of lactating mothers in order to help the newborn overcome the stressful perinatal events of natural labor and delivery."

Now let's think about this for a minute. On the 4th postpartum day colostrum endorphin levels are higher? I take it to mean that at all other times they were equivalent or lower. So how exactly is a single elevated colostrum endorphin level on the 4th postpartum day supposed to be helping neonates recover from the effects of delivery? The authors can suggest the conclusion all they want, but there is no reason to believe it.

Third study: "These findings suggest for the first time that labour is associated with a marked increase of NBDZ which could be envisaged as a stress-related event."

No one knows what these compounds do, including the authors. They don't even try to suggests that NBDZ are beneficial to anybody in any way. The authors offer a tentative hypothesis that they might represent the body's response to the stress of labor. The paper does not show (and authors do not conclude) that these compounds are either effective or beneficial.

The fourth study is not about pain in labor either. It is about the effect of birth asphyxia on the hypothalamic-pituitary-adrenal axis.

By Blogger Amy Tuteur, MD, at 8:23 AM